早期止血与降低死亡率和并发症发生率相关：来自实用随机最佳血小板与血浆比例试验的结果。
Earlier time to hemostasis is associated with decreased mortality and rate of complications: Results from the Pragmatic Randomized Optimal Platelet and Plasma Ratio trial.
机构信息
From the Center for Translational Injury Research (R.C., K.J.K., E.E.F., B.A.C., J.M.P., C.E.W., J.B.H.), University of Texas Health Science Center; Department of Surgery (R.C., K.J.K., E.E.F., B.A.C., C.E.W., J.B.H.), McGovern Medical School, Houston, Texas; Department of Surgery (J.D.K.), University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; Department of Biostatistics and Environmental and Occupational Health Sciences (G.V.B.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (M.J.C.), University of Colorado School of Medicine, Denver, Colorado; Department of Surgery (M.A.S., K.B.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (E.M.B), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (K.I.), University of Southern California School of Medicine, Los Angeles, California; and Department of Surgery (S.R.), University of Toronto, Toronto, Canada.
出版信息
J Trauma Acute Care Surg. 2019 Aug;87(2):342-349. doi: 10.1097/TA.0000000000002263.
BACKDROP
Clinicians intuitively recognize that faster time to hemostasis is important in bleeding trauma patients, but these times are rarely reported.
METHODS
Prospectively collected data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial were analyzed. Hemostasis was predefined as no intraoperative bleeding requiring intervention in the surgical field or resolution of contrast blush on interventional radiology (IR). Patients who underwent an emergent (within 90 minutes) operating room (OR) or IR procedure were included. Mixed-effects Poisson regression with robust error variance (controlling for age, Injury Severity Score, treatment arm, injury mechanism, base excess on admission [missing values estimated by multiple imputation], and time to OR/IR as fixed effects and study site as a random effect) with modified Bonferroni corrections tested the hypothesis that decreased time to hemostasis was associated with decreased mortality and decreased incidence of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), multiple-organ failure (MOF), sepsis, and venous thromboembolism.
RESULTS
Of 680 enrolled patients, 468 (69%) underwent an emergent procedure. Patients with decreased time to hemostasis were less severely injured, had less deranged base excess on admission, and lower incidence of blunt trauma (all p < 0.05). In 408 (87%) patients in whom hemostasis was achieved, every 15-minute decrease in time to hemostasis was associated with decreased 30-day mortality (RR, 0.97; 95% confidence interval [CI], 0.94-0.99), AKI (RR, 0.97; 95% CI, 0.96-0.98), ARDS (RR, 0.98; 95% CI, 0.97-0.99), MOF (RR, 0.94; 95% CI, 0.91-0.97), and sepsis (RR, 0.98; 95% CI, 0.96-0.99), but not venous thromboembolism (RR, 0.99; 95% CI, 0.96-1.03).
CONCLUSION
Earlier time to hemostasis was independently associated with decreased incidence of 30-day mortality, AKI, ARDS, MOF, and sepsis in bleeding trauma patients. Time to hemostasis should be considered as an endpoint in trauma studies and as a potential quality indicator.
LEVEL OF EVIDENCE
Therapeutic/care management, level III.
背景
临床医生直观地认识到，出血性创伤患者的止血时间越短越好，但这些时间很少被报道。
方法
对 Pragmatic Randomized Optimal Platelet and Plasma Ratios 试验的前瞻性采集数据进行了分析。止血定义为术中无需在手术部位进行干预的出血，或者介入放射学（IR）中对比剂外渗消退。纳入接受紧急（90 分钟内）手术室（OR）或 IR 手术的患者。采用混合效应泊松回归模型进行分析，该模型采用稳健误差方差（控制年龄、损伤严重程度评分、治疗臂、损伤机制、入院时的基础不足[用多重插补法估计缺失值]以及 OR/IR 时间作为固定效应，研究地点作为随机效应），并进行了修正后的 Bonferroni 校正，以检验以下假设：止血时间缩短与死亡率降低和急性肾损伤（AKI）、急性呼吸窘迫综合征（ARDS）、多器官功能衰竭（MOF）、败血症和静脉血栓栓塞（VTE）发生率降低相关。
结果
在 680 名入组患者中，有 468 名（69%）接受了紧急手术。止血时间缩短的患者损伤程度较轻，入院时的基础不足值紊乱程度较轻，钝性创伤发生率较低（均 p < 0.05）。在 408 名（87%）达到止血的患者中，每缩短 15 分钟的止血时间，30 天死亡率（RR，0.97；95%置信区间[CI]，0.94-0.99）、AKI（RR，0.97；95% CI，0.96-0.98）、ARDS（RR，0.98；95% CI，0.97-0.99）、MOF（RR，0.94；95% CI，0.91-0.97）和败血症（RR，0.98；95% CI，0.96-0.99）的发生率降低，但静脉血栓栓塞（RR，0.99；95% CI，0.96-1.03）的发生率无变化。
结论
止血时间越早与出血性创伤患者 30 天死亡率、AKI、ARDS、MOF 和败血症发生率降低独立相关。止血时间应被视为创伤研究中的一个终点，并作为潜在的质量指标。
证据水平
治疗/护理管理，III 级。
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